Overwhelming Postsplenectomy Infection: A Prospective Multicenter Cohort Study

Updated Recommendations on the Prevention and Treatment of Infections in Children With Asplenia/Hyposplenism

Children with congenital or acquired asplenia or hyposplenism have an increased risk for severe and even life-threatening infections mainly due to encapsulated bacteria. Current practice focuses on preventing severe infections with timely administration of vaccinations, antibacterial prophylaxis when indicated, and urgent evaluation and treatment of febrile events. As new vaccines are now available for both children and adults with asplenia/hyposplenism, we present an up-to-date recommendation on the prevention and management of acute infections in children with asplenia/hyposplenism.

Laparoscopic spleen-preserving total pancreatectomy for the treatment of low-grade malignant pancreatic tumors: Two case reports and review of literature

BACKGROUND

Function-preserving pancreatectomy can improve the long-term quality of life of patients with benign or low-grade malignant tumors, such as intraductal papillary mucinous neoplasms (IPMNs) and mucinous cystic neoplasms. However, there is limited literature on laparoscopic spleen-preserving total pancreatectomy (L-SpTP) due to technical difficulties.

CASE SUMMARY

Patient 1 was a 51-year-old male diagnosed with IPMN based on preoperative imaging, showing solid nodules in the pancreatic head and diffuse dilation of the main pancreatic duct with atrophy of the distal pancreas. We performed L-SpTP with preservation of the splenic vessels, and the postoperative pathology report revealed IPMN with invasive carcinoma. Patient 2 was a 60-year-old male with multiple cystic lesions in the pancreatic head and body. L-SpTP was performed, and intraoperatively, the splenic vein was injured and required ligation. Postoperative pathology revealed a mucinous cystic tumor of the pancreas with low-grade dysplasia. Both patients were discharged on postoperative day 7, and there were no major complications during the perioperative period.

CONCLUSION

We believe that L-SpTP is a safe and feasible treatment for low-grade malignant pancreatic tumors, but more case studies are needed to evaluate its safety, efficacy, and long-term outcomes.

Splenic artery embolisation for splenic injury during colonoscopy: A systematic review

BACKGROUND

Splenic injury due to colonoscopy is rare, but has high mortality. While historically treated conservatively for low-grade injuries or with splenectomy for high-grade injuries, splenic artery embolisation is increasingly utilised, reflecting modern treatment guidelines for external blunt trauma. This systematic review evaluates outcomes of published cases of splenic injury due to colonoscopy treated with splenic artery embolisation.

METHODS

A systematic review was performed of published articles concerning splenic injury during colonoscopy treated primarily with splenic artery embolisation, splenectomy, or splenorrhaphy from 1977 to 2022. Datapoints included demographics, past surgical history, indication for colonoscopy, delay to diagnosis, treatment, grade of injury, splenic artery embolisation location, splenic preservation (salvage), and mortality.

RESULTS

The 30 patients treated with splenic artery embolisation were of mean age 65 (SD 9) years and 67% female, with 83% avoiding splenectomy and 6.7% mortality. Splenic artery embolisation was proximal to the splenic hilum in 81%. The 163 patients treated with splenectomy were of mean age 65 (SD 11) years and 66% female, with 5.5% mortality. Three patients treated with splenorrhaphy of median age 60 (range 59-70) years all avoided splenectomy with no mortality. There was no difference in mortality between splenic artery embolisation and splenectomy cohorts (p = 0.81).

CONCLUSIONS

Splenic artery embolisation is an effective treatment option in splenic injury due to colonoscopy. Given the known benefits of splenic salvage compared to splenectomy, including preserved immune function against encapsulated organisms, low cost, and shorter hospital length of stay, embolisation should be incorporated into treatment pathways for splenic injury due to colonoscopy in suitable patients.

Efficacy of a novel patient-focused intervention aimed at increasing adherence to guideline-based preventive measures in asplenic patients: the PrePSS trial

PURPOSE

To determine whether a novel intervention improves the adherence to guideline-based preventive measures in asplenic patients at risk of post-splenectomy sepsis (PSS).

METHODS

We used a prospective controlled, two-armed historical control group design to compare a novel, health action process approach (HAPA)-based telephonic intervention involving both patients and their general practitioners to usual care. Eligible patients were identified in cooperation with the insurance provider AOK Baden-Wuerttemberg, Germany. Patients with anatomic asplenia (n = 106) were prospectively enrolled and compared to a historical control group (n = 113). Comparisons were done using a propensity-score-based overlap-weighting model. Adherence to preventive measures was quantified by the study-specific 'Preventing PSS score' (PrePSS score) which includes pneumococcal and meningococcal vaccination status, the availability of a stand-by antibiotic and a medical alert card.

RESULTS

At six months after the intervention, we estimated an effect of 3.96 (95% CI 3.68-4.24) points on the PrePSS score scale (range 0-10) with mean PrePSS scores of 3.73 and 7.70 in control and intervention group, respectively. Substantial improvement was seen in all subcategories of the PrePSS score with the highest absolute gains in the availability of stand-by antibiotics. We graded the degree of participation by the general practitioner (no contact, short contact, full intervention) and noted that the observed effect was only marginally influenced by the degree of physician participation.

CONCLUSIONS

Patients who had received the intervention exhibited a significantly higher adherence to guideline-based preventive measures compared to the control group. These data suggest that widespread adoption of this pragmatic intervention may improve management of asplenic patients. Health insurance provider-initiated identification of at-risk patients combined with a patient-focused intervention may serve as a blueprint for a wide range of other preventive efforts leading to patient empowerment and ultimately to better adherence to standards of care.

Invasive Pneumococcal Diseases in Korean Adults After the Introduction of Pneumococcal Vaccine into the National Immunization Program

Although Streptococcus pneumoniae has been one of the most common bacterial causes of disease in humans, its impact has been blunted by the broad use of vaccines. Since 2018, the incidence of invasive pneumococcal disease in Korea decreased with effective pneumococcal vaccines but is on the rise again recently. In this paper I will review the epidemiology, risk factors, and antibiotic resistance of invasive pneumococcal disease after the introduction of the pneumococcal vaccine in Korean adults.

Adherence to vaccination guidelines of patients with complete splenectomy in Norway, 2008-2020

The spleen is responsible for blood filtration and mounting an immune response against pathogens. In some people the spleen must be surgically removed because of traumatic events or oncological and hematological conditions. These patients are at higher risk of developing diseases caused by encapsulated bacteria throughout their lives. Thus, immunisations are advised for splenectomised persons to prevent infection caused by Streptococcus pneumoniae, Neisseria meningitidis and Haemophilus influenzae type b (Hib). This study assessed vaccination coverage (VC) among Norwegian patients with surgical asplenia. Using the Nomesco Classification of Surgical Procedures codes, patient information (age, sex, date of initial diagnosis and date of surgery) was acquired from the Norwegian Patient Registry. The National Immunization Register provided information on vaccination status and data of any subsequent invasive bacterial infections were obtained from the Norwegian Surveillance System for Communicable Diseases. From the total population of Norway, 3155 patients who had undergone complete splenectomy were identified. Of these, 914 (29.0%) had received at least one dose of pneumococcal conjugate vaccine (PCV), 1324 (42.0%) at least one dose of pneumococcal polysaccharide vaccine and 589 (18.7%) had received both. Only 4.2% of the patients had received two doses of a meningococcal ACWY conjugate vaccine, while 8.0% of 1467 patients splenectomised after 2014 had received at least two doses of a serogroup B meningococcal vaccine. The VC for Hib was 18.7%. Nearly all splenectomised children under the age of 10 were vaccinated with Hib and PCV as these vaccines are included in the childhood immunisation program. For all vaccines, VC decreased with age. Twenty-nine invasive bacterial infections were registered post-splenectomy in 25 patients. Vaccination according to national recommendations could have prevented at least 8 (28%) of these infections. Our study showed that efforts are required to increase VC of splenectomised individuals in Norway.

Effects of a health psychology-based intervention for patients with asplenia on psychological determinants of preventive behaviour: A propensity score analysis

OBJECTIVE

Patients with asplenia have an increased lifelong risk of severe infections especially post splenectomy sepsis with hospital mortality rates of 30-50%. Adherence to existing guidelines for preventive measures is low. Objective of the study is the evaluation of a novel intervention to increase health psychological outcomes in patients with asplenia resulting in better adherence to preventive measures.

METHODS

The intervention was evaluated by conducting a prospective, two-armed historical control group design via propensity score analysis. Focus are health-psychological outcomes: self-efficacy, intention, risk perception, behaviour planning, self-management, health literacy, patient involvement and disease-knowledge.

RESULTS

Patients in the intervention group (N = 110) showed a higher increase in almost all outcomes compared to a historical control group (N = 115). The strongest increase was observed in "asplenia-specific self-management" (average treatment effect: ATE 1.14 [95% CI 0.91-1.36] p < .001) and "asplenia-specific health-literacy" (ATE 1.42 [95% CI 1.18-1.65] p < .001). Significant intervention effects were also found in behaviour planning, perceived involvement and disease-knowledge.

CONCLUSION

The patient-focused intervention is effective in improving health-psychological outcomes in patients with asplenia.

PRACTICE IMPLICATIONS

The implementation of the intervention can make an important contribution to care and lead to an improvement of health-psychological outcomes that may result in a higher adherence to prevention measures.

Streptococcal pyomyositis in asplenia and underlying connective tissue disease

Pyomyositis is an infection of skeletal muscles, commonly affecting deep longitudinal muscles of the lower extremities. Primary pyomyositis is uncommon in the United States. Staphylococcus aureus is the most common cause of pyomyositis, but Streptococcus pneumoniae is the most common cause of life-threatening bacterial infection in asplenic patients. Most cases of S. pneumoniae pyomyositis occur in immunocompromised patients. We describe a 31-year-old man with S. pneumoniae pyomyositis whose diagnosis and hospital course were complicated by an immunocompromised state from asplenia and an underlying connective tissue disease, Stickler syndrome. Underlying connective tissue diseases such as systemic lupus erythematosus and polymyositis can predispose patients to infection, but susceptibility with Stickler syndrome is less known. While pyomyositis is only seen in up to 0.2% of US hospital admissions, it remains a pertinent differential for patients with asplenia and connective tissue disease.

[Spleen-preserving total pancreatectomy for low-grade tumors]

OBJECTIVE

To justify organ-preserving variants of total pancreatectomy.

MATERIAL AND METHODS

We retrospectively analyzed the results of classic and modified total pancreatectomy between September 2010 and March 2021. Implementing pylorus-sparing total pancreatectomy with preservation of stomach, spleen, gastric and splenic vessels, we thoroughly analyzed exocrine/endocrine disorders after total pancreatectomy and changes in immune status after splenectomy. Serum C-reactive protein and ferritin were assessed in 1, 3, 5, 7, 14 and 30 days after surgery in both groups. We also estimated daily glycemic profile after total pancreatectomy in classical and organ-preserving modifications.

RESULTS

We performed 37 total pancreatectomies including 12 pylorus-preserving total pancreatectomies with preservation of stomach, spleen, gastric and splenic vessels. General and specific postoperative complication rate was significantly lower after modified surgery compared to classic total pancreatectomy with gastric resection and splenectomy.

CONCLUSION

Modified total pancreatectomy is preferable for low-grade pancreatic tumors.

[Stomach and spleen preserving total pancreatectomy]

INTRODUCTION

Pancreatic surgery expands the indications and the use of total pancreatectomy. Considering a rather high rate of postoperative complications, the search for the ways to improve its outcomes is extremely relevant. The purpose of this study is justification and implementation of organ-preserving variants of total pancreatectomy.

MATERIAL AND METHODS

Retrospective analysis of treatment results after classic and modified total pancreatectomy in the surgical clinic of Botkin Hospital was performed from September 2010 to March 2021. During the development and implementation of pylorus-preserving total pancreatectomy with preservation of the stomach, spleen, gastric and splenic vessels, we thoroughly analyzed aspects of exocrine/endocrine disorders and changes of the immune status after performing the modified technique.

RESULTS

We performed 37 total pancreatectomies, including 12 pylorus-preserving total pancreatectomies with preservation of the stomach, spleen, gastric, and splenic vessels. General and specific postoperative complication rate in patients after the modified operation was significantly lower compared to the results of classic total pancreatectomy with gastric resection and splenectomy.

CONCLUSION

Modified total pancreatectomy is a method of choice for pancreatic tumors of low malignant potential.

Patients' with asplenia and doctors' experiences in implementing preventative measures following a novel educational intervention: a qualitative analysis

OBJECTIVE

To explore patients' with asplenia and general practitioners' (GPs) (1) perceptions of a novel, Health Action Process Approach (HAPA)-based, educational intervention which targets to increase adherence to post-splenectomy sepsis (PSS) prevention measures and (2) their experience in implementing prevention measures following this intervention.

DESIGN

A process evaluation conducted on average 3.5 (for patients) and 3.8 (for GPs) months after the intervention between January 2020 and April 2021 individually by means of semi-structured guideline-based telephone interviews. Data was analysed using qualitative content analysis.

PARTICIPANTS

Volunteer subsample of N=25 patients with asplenia and N=8 GPs who received the intervention. Inclusion criteria were met by prior participation in the intervention (German-speaking, of full age and insured by the cooperating health insurance). Patient selection was done by purposeful selection aiming at maximum variability in terms of adherence to preventative measures prior to intervention participation. Participating GPs are a non-purposeful selected convenience sample. For reasons of data protection, no personal data was collected.

RESULTS

The intervention was positively evaluated and its personal relevancy for patients and for the GPs' professional work became apparent. The intervention promoted risk awareness, intention to action, action planning and subsequently, improved adherence to preventative measures. Helpful factors for implementation among the patients were social support by relatives and GPs. Barriers to adherence identified in both groups can be divided into patient-attributed (eg, comorbidities), doctor-related (eg, lack of knowledge or support) as well as contextual factors (eg, vaccine supply constraints).

CONCLUSIONS

Our findings indicate a patient and GP perceived benefit of the intervention, but still identify prevailing barriers to implementation. In a further step, a quantitative evaluation of the intervention will be conducted and recommendations for integrating the intervention in usual care will be made.

TRIAL REGISTRATION NUMBER

DRKS00015238.

Bacterial Etiology of Fever Episodes of Splenectomized Patients in Three Medical Centers in the City of Mashhad in Northeastern Iran

Background: Many medical and surgical conditions may need to be treated with splenectomy. As this lymphoid tissue plays an important role in controlling various infections, and many life-threatening infections can occur in the absence of the spleen, any episode of fever should be taken seriously. Objectives: This study aims to assess the bacterial etiology of fever episodes in splenectomized patients in three medical centers in Mashhad, a city in northeastern Iran. Methods: Between 2006 and 2017, splenectomized patients in Imam Reza, Ghaem, and Dr. Sheikh hospitals were included in a cross-sectional study. Data collected included, age at splenectomy, hospitalization duration, indications for admission to the intensive care unit, vital signs at admission, bacterial species responsible for sepsis, times of hospitalization due to fever episodes, clinical signs and symptoms, antibiotic prophylaxis, and outcomes at six and one years. The data were analyzed using SPSS Statistics 20. Results: A total of 280 splenectomized patients were reviewed, and 23 of them had episodes of fever. The most common causes of splenectomy were spleen masses and idiopathic thrombocytopenic purpura (ITP), each accounting for 17.4% of cases. The mean age of the patients was 24.2 ± 1.6 years. 47.8% of the patients were male, and 52.2% were female. The median admission duration was seven days. A majority of admissions were due to intra-abdominal infections (26.7%), pneumonia (13.3%), and bacteremia (10.0%). There were 30 episodes of fever recorded, of which 2 (6.7%) resulted in death. Blood culture was positive in four cases (13.3%) for Streptococcus pneumoniae, Staphylococcus aureus, Citrobacter, and Brucella. A suitable antibiotic coverage was obtained in 13.3% of cases (i.e., ceftriaxone + vancomycin or fluoroquinolone + vancomycin), and a minimum suitable empiric coverage was obtained in 10.0% of cases, and no appropriate antibiotic coverage was obtained in 76.7% of cases. Conclusions: The present study highlights widespread inappropriate empiric therapy of fever episodes in splenectomized patients, as well as a lack of due attention to timely sample collection before antibiotic administration. Despite this, the isolated organisms were varied and included S. pneumoniae, S. aureus, coagulase negative staphylococci, P. aeruginosa, Brucella, and Citrobacter.

The Impact of Standardized Infectious Diseases Consultation on Post-Splenectomy Care and Outcomes

Background

Patients who receive splenectomy are at risk for overwhelming postsplenectomy infection (OPSI). Guidelines recommend that adult asplenic patients receive a complement of vaccinations, education on the risks of OPSI, and on-demand antibiotics. However, prior literature suggests a majority of patients who have had a splenectomy receive incomplete asplenic patient care and thus remain at increased risk. This study assessed the impact of standardized involvement of infectious diseases (ID) providers on asplenic patient care outcomes in patients undergoing splenectomy.

Methods

A quasi-experimental study design compared a prospective cohort of patients undergoing splenectomy from August 2017 to June 2021 who received standardized ID involvement in care of the asplenic patient with a historic control cohort of patients undergoing splenectomy at the same institution from January 2010 through July 2017 who did not. There were 11 components of asplenic patient care defined as primary outcomes. Secondary outcomes included the occurrence of OPSI, death, and death from OPSI.

Results

50 patients were included in the prospective intervention cohort and 128 in the historic control cohort. There were significant improvements in 9 of the 11 primary outcomes in the intervention arm as compared to the historic controls. Survival analysis showed no statistically significant difference in the incidence of OPSI-free survival between the groups (p = 0.056), though there was a trend towards improvement in the prospective intervention arm.

Conclusions

Standardized involvement of an ID provider in the care of patients undergoing splenectomy improves asplenic patient care outcomes. Routine involvement of ID in this setting may be warranted.

Laparoscopic management of benign splenic tumors in children

Background

The splenic tumor is relatively rare in children. However, diagnosing and managing this disease remain controversial. This study aimed to evaluate the clinical characteristics and pathological features of benign splenic tumors and to explore the feasibility and safety of laparoscopic splenectomy in children.

Methods

The clinical data of all patients who were diagnosed with benign splenic tumors and admitted to our center between January 2014 and December 2020 were analyzed retrospectively. Factors that were documented included demographic criteria, clinical manifestations, preoperative examinations, surgical methods, histopathological characteristics, postoperative complications and outcomes.

Results

Totally, 24 consecutive patients with a mean age of 10.21±2.59 years were operated laparoscopically. Nine patients presented with recurrent abdominal pain, vomiting or backache. The remaining 15 cases were asymptomatic and were identified incidentally. Laparoscopic total splenectomy (LTS) was performed in 12 cases, laparoscopic partial splenectomy (LPS) in 9 cases and deroofing of splenic cyst in 3 cases. No significant differences were observed in operation time, intraoperative bleeding and postoperative abdominal drainage between the LTS and LPS groups. Histopathology examination reported 12 cases of splenic epithelial cyst, 5 cases of splenic lymphangioma or lymphatic malformation, 3 cases of splenic hamartoma, 3 cases of splenic littoral cell angioma and 1 case of splenic hemangioma. No postoperative complications and tumor recurrence were observed.

Conclusions

It is still difficult to precisely diagnose the splenic tumor preoperatively. Laparoscopic splenectomy is safe and feasible in treating the benign splenic tumors, and partial splenectomy is of great significance in preserving the immune function in children.

Purpura fulminans due to Enterococcus cecorum in an asplenic patient

Enterococcus cecorum was initially isolated from the intestine of poultry and is an uncommon cause of human infection. We report here what we believe to be the first case of overwhelming post-splenectomy infection (OPSI) with purpura fulminans due to Enterococcus cecorum in a 51-year-old man. As opposed to other enterococci, Enterococcus cecorum remains susceptible to third-generation cephalosporin which is the first line empirical antibiotic therapy for both patients with purpura fulminans and asplenic patients with sepsis. Despite adequate antibiotic therapy, evolution in the intensive care unit (ICU) was overwhelming with death occurring 10 h after ICU admission.

Functional vulnerability of liver macrophages to capsules defines virulence of blood-borne bacteria

Many encapsulated bacteria use capsules to cause invasive diseases. However, it remains largely unknown how the capsules enhance bacterial virulence under in vivo infection conditions. Here we show that the capsules primarily target the liver to enhance bacterial survival at the onset of blood-borne infections. In a mouse sepsis model, the capsules enabled human pathogens Streptococcus pneumoniae and Escherichia coli to circumvent the recognition of liver-resident macrophage Kupffer cells (KCs) in a capsular serotype-dependent manner. In contrast to effective capture of acapsular bacteria by KCs, the encapsulated bacteria are partially (low-virulence types) or completely (high-virulence types) "untouchable" for KCs. We finally identified the asialoglycoprotein receptor (ASGR) as the first known capsule receptor on KCs to recognize the low-virulence serotype-7F and -14 pneumococcal capsules. Our data identify the molecular interplay between the capsules and KCs as a master controller of the fate and virulence of encapsulated bacteria, and suggest that the interplay is targetable for therapeutic control of septic infections.

Immune function and the role of vaccination after splenic artery embolization for blunt splenic injury

The spleen is the most commonly injured solid organ following blunt abdominal trauma. Over recent decades, splenic artery embolization (SAE) has become the mainstay treatment for haemodynamically stable patients with high-grade blunt splenic trauma, with splenectomy the mainstay of treatment for unstable patients. Splenic function is complex but the spleen has an important role in immune function, particularly in protection against encapsulated bacteria. Established evidence suggests that following splenectomy immune function is impaired resulting in increased susceptibility to overwhelming post-splenectomy infection, however, immune function may be preserved following SAE. This review will discuss the current state of the literature on immune function following different treatments of blunt splenic injury, and the controversies surrounding what constitutes a quantitative test of splenic immune function.

[Vaccinations]

Vaccination is considered one of the most important achievements of modern medicine and has saved millions of lives. As a result, the age-old fear of severe or fatal infectious diseases has largely been forgotten in society; however, the pandemic triggered by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) shows how quickly this fear can return. Also, many people have reservations about medical measures, especially if they are directed against vague dangers. Paradoxically, the success of vaccinations jeopardizes the acceptance. To counteract this development, this article provides information on basic vaccination principles, legal frameworks and components of vaccines. It explains the most important categories, goals, core elements of vaccination programs and the most important recommendations of the Standing Committee on Vaccination at the Robert Koch Institute (STIKO). It explains the current state of knowledge with respect to required resources, assessment of vaccine reactions, complication management and possible vaccine damage.

Splenic macrophages as the source of bacteraemia during pneumococcal pneumonia

Background

Severe community-acquired pneumococcal pneumonia is commonly associated with bacteraemia. Although it is assumed that the bacteraemia solely derives from pneumococci entering the blood from the lungs it is unknown if other organs are important in the pathogenesis of bacteraemia. Using three models, we tested the relevance of the spleen in pneumonia-associated bacteraemia.

Methods

We used human spleens perfused ex vivo to explore permissiveness to bacterial replication, a non-human primate model to check for splenic involvement during pneumonia and a mouse pneumonia-bacteraemia model to demonstrate that splenic involvement correlates with invasive disease.

Findings

Here we present evidence that the spleen is the reservoir of bacteraemia during pneumonia. We found that in the human spleen infected with pneumococci, clusters with increasing number of bacteria were detectable within macrophages. These clusters also were detected in non-human primates. When intranasally infected mice were treated with a non-therapeutic dose of azithromycin, which had no effect on pneumonia but concentrated inside splenic macrophages, bacteria were absent from the spleen and blood and importantly mice had no signs of disease.

Interpretation

We conclude that the bacterial load in the spleen, and not lung, correlates with the occurrence of bacteraemia. This supports the hypothesis that the spleen, and not the lungs, is the major source of bacteria during systemic infection associated with pneumococcal pneumonia; a finding that provides a mechanistic basis for using combination therapies including macrolides in the treatment of severe community-acquired pneumococcal pneumonia.

Funding

Oxford University, Wolfson Foundation, MRC, NIH, NIHR, and MRC and BBSRC studentships supported the work.

Secondary immunodeficiencies: An overview

OBJECTIVE

To review the different causes of secondary immunodeficiencies and provide clinicians with an updated overview of potential factors that contribute to immunodeficiency.

DATA SOURCES

Recent published literature obtained through PubMed database searches, including research articles, review articles, and case reports.

STUDY SELECTIONS

PubMed database searches were conducted using the following keywords: immunodeficiency, antibody deficiency, immunosuppressive drugs, genetic syndrome, malignancy, HIV infection, viral infection, secondary immunodeficiency, nutrition, prematurity, aging, protein-losing enteropathy, nephropathy, trauma, space travel, high altitude, and ultraviolet light. Studies published in the last decade and relevant to the pathogenesis, epidemiology, and clinical characteristics of secondary immunodeficiencies were selected and reviewed.

RESULTS

Researchers continue to investigate and report abnormal immune parameters in the different entities collectively known as secondary immunodeficiencies. Immunodeficiency might occur as a consequence of malnutrition, metabolic disorders, use of immunosuppressive medications, chronic infections, malignancies, severe injuries, and exposure to adverse environmental conditions. The neonate and the elderly may have decreased immune responses relative to healthy adults. Each of these conditions may present with different immune defects of variable severity. The acquired immunodeficiency syndrome results from infections by the human immunodeficiency virus, which targets CD4 T cells leading to defective immune responses. Rituximab is a monoclonal antibody that targets CD20 B cells, and its use might result in persistent hypogammaglobulinemia.

CONCLUSION

Clinicians should consider secondary immunodeficiencies in the differential diagnosis of a patient with recurrent infections and abnormal immunologic evaluation. The use of biological agents for the treatment of inflammatory conditions and malignancies is an increasingly important cause of secondary immunodeficiency.

Skin and sepsis: contribution of dermatology to a rapid diagnosis

In patients who develop sepsis, whether due to primary, secondary or metastatic lesions, the skin is frequently affected. However, there are unresolved aspects regarding the general clinical manifestations in the skin or the prognosis and/or therapeutic implications. The main challenge in the approach to sepsis is its early diagnosis and management. In this review, we address the sepsis-skin relationship and the potential impact of early dermatological intervention on the septic patient through ten basic questions. We found little evidence of the participation of the dermatologist in sepsis alert programs. There are early skin changes that may alert clinicians on a possible sepsis, such as skin mottling or variations in acral skin temperature. In addition, the skin is an accessible and highly cost-effective tissue for etiological studies of some forms of sepsis (e.g., meningococcal purpura) and its involvement defines the prognosis of certain patients (e.g., infective endocarditis).

Immunization coverage among asplenic patients and strategies to increase vaccination compliance: a systematic review and meta-analysis

BACKGROUND

Asplenic or splenectomized patients have a higher risk (ranging from 10 to 50-fold) than the general population of developing an overwhelming post-splenectomy infection (OPSI). Thus, they should receive specific vaccinations to prevent bacterial infections and influenza. The aim of this meta-analysis was to estimate vaccination coverage (VC) with the recommended vaccines among splenectomized patients; strategies recommended in those studies to improve VC worldwide are considered as well.

RESEARCH DESIGN AND METHODS

Scopus, MEDLINE/PubMed, Google Scholar and ISI Web of Knowledge databases were searched. Research papers, short reports, reviews, and meta-analyses published between January 1, 2010 and July 18, 2020 were included; no geographic restrictions were included. Twenty-four studies were included in the meta-analysis.

RESULTS

For anti-pneumococcal vaccination, coverage was 55.1% (95%CI = 41.0-69.2%), for anti-Hib 48.3% (95%CI = 34.3-52.3%), for anti-meningococcal C/ACYW135 33.7% (95%CI = 23.6-43.9%), for anti-meningococcal B 13.3% (95%CI = 7.0-19.5%) and for anti-influenza 53.2% (95%CI = 22.0-84.4%). Most studies determined a lack of adherence to international guidelines by healthcare workers and suggested the need to better educate health professionals in the management of post-splenectomy patients.

CONCLUSIONS

The meta-analysis showed the suboptimal immunization coverage for the vaccines recommended for asplenic patients. Greater efforts must be made by public health professionals to increase VC in this group of patients at risk. Introducing specific prophylaxis protocols in the clinical routine seems to guarantee better immunization compliance in those patients.

Preventing infections in children and adults with asplenia

An estimated 1 million people in the United States have functional or anatomic asplenia or hyposplenia. Infectious complications due to encapsulated organisms such as Streptococcus pneumoniae, Neisseria meningitidis, and Haemophilus influenzae can lead to fulminant sepsis and death, particularly in young children, in the period shortly after splenectomy, and in immunocompromised patients. Patients with asplenia are also at risk for less common infections due to Capnocytophaga, Babesia, and malaria. Antibiotic prophylaxis, vaccines, and patient and family education are the mainstays of prevention in these at-risk patients. Recommendations for antibiotic prophylaxis typically target high-risk periods, such as 1 to 3 years after splenectomy, children ≤5 years of age, or patients with concomitant immunocompromise. However, the risk for sepsis is lifelong, with infections occurring as late as 40 years after splenectomy. Currently available vaccines recommended for patients with asplenia include pneumococcal vaccines (13-valent pneumococcal conjugate vaccine followed by the 23-valent pneumococcal polysaccharide vaccine), meningococcal vaccines (meningococcal conjugate vaccines for serogroups A, C, Y and W-135 and serogroup B meningococcal vaccines), H. influenzae type b vaccines, and inactivated influenza vaccines. Ongoing booster doses are also recommended for pneumococcal and meningococcal vaccines to maintain protection. Despite the availability of prevention tools, adherence is often a challenge. Dedicated teams or clinics focused on patient education and monitoring have demonstrated substantial improvements in vaccine coverage rates for individuals with asplenia and reduced risk of infection. Future efforts to monitor the quality of care in patients with asplenia may be important to bridge the know-do gap in this high-risk population.

Laparoscopic surgery for splenic injuries in the era of non-operative management: current status and future perspectives

The spleen is one of the organs most commonly injured by blunt abdominal trauma. It plays an important role in immune response to infections, especially those sustained by encapsulated bacteria. Nonoperative management (NOM), comprising clinical and radiological observation with or without angioembolization, is the treatment of choice for traumatic splenic injury in patients who are hemodynamically stable. However, this strategy carries a risk of failure, especially for high-grade injuries. No clear predictors of failure have been identified, but minimally invasive surgery for splenic injury is gaining popularity. Laparoscopic surgery has been proposed as an alternative to open surgery for hemodynamically stable patients who require surgery, such as after failed NOM. We reviewed research articles on laparoscopic surgery for hemodynamically stable patients with splenic trauma to explore the current knowledge about this topic. After presenting an overview of the treatments for splenic trauma and the immunological function of the spleen, we try to identify the future indications for laparoscopic surgery in the era of NOM.

Perioperative Immunization for Splenectomy and the Surgeon's Responsibility: A Review

Importance

Patients who have had splenectomy have a lifelong risk of overwhelming postsplenectomy infection (OPSI), a condition associated with high mortality rates. Surgeons must be aware of the rationale of vaccination in the case of splenectomy, to provide appropriate immunization in the perioperative time.

Observations

English-language articles published from January 1, 1990, to December 31, 2019, were retrieved from MEDLINE/PubMed, Cochrane Library, and ClinicalTrials.gov databases. Randomized clinical trials as well as systematic reviews and observational studies were considered. Asplenia yields an impairment of both innate and adaptive immunity, thus increasing the risk of severe encapsulated bacterial infections. Current epidemiology of OPSI ranges from 0.1% to 8.5% but is hard to ascertain because of ongoing shifts in patients' baseline conditions and vaccine penetration. Despite the lack of randomized clinical trials, immunization appears to be effective in reducing OPSI incidence. Unfortunately, vaccination coverage is still suboptimal, with a great variability in vaccination rates being reported across institutions and time frames. Notably, current guidelines do not advocate any particular health care qualification responsible for vaccine prescription or administration. Given the dearth of high-level basic science or clinical evidence, the optimal vaccination timing and the need for booster doses are not yet well established. Although almost all guidelines indicate to not administer vaccines within 14 days before and after surgery, most data suggest that immunization might be effective even in the immediate perioperative time, thus placing the surgeon in a primary position for vaccine delivery. Furthermore, revaccination schedules are the target of ongoing debates, since a vaccine-driven hyporesponsiveness has been postulated.

Conclusions and Relevance

In patients who have undergone splenectomy, OPSI might be effectively prevented by proper immunization. Surgeons have the primary responsibility for achieving adequate, initial immunization in the setting of both planned and urgent splenectomy.

Impact of a pharmacist-led intervention on post-splenectomy vaccination adherence among trauma patients

Background

Patients who undergo splenectomy are at increased risk of infection caused by encapsulated bacteria. The Advisory Committee on Immunization Practices recommends a series of vaccinations for asplenic patients, the first of which are generally completed prior to hospital discharge in the setting of trauma. However, studies suggest that trauma patients receive booster vaccinations at a suboptimal rate. The aim of this study was to evaluate the impact of an inpatient, pharmacist-led post-splenectomy counseling service on patient understanding and patient-reported revaccination follow-up rate.

Methods

Patients who underwent splenectomy due to trauma between October 2017 and February 2019 were surveyed via telephone questionnaire at least eight weeks after initial vaccination. Responses were compared to historical data which was collected prior to the service implementation. The primary outcome was patient reported follow-up vaccination rate. Secondary outcomes included patient awareness of vaccine requirements and need for rehospitalization.

Results

A total of 67 patients met inclusion criteria, of whom 31 (46%) were successfully contacted by phone. After implementation of the post-splenectomy counseling service, 14 patients (45.2%) reported receiving second doses of pneumococcal and meningococcal vaccines, compared to 6 patients (6.3%) in the pre-implementation cohort ( p = 0.000001). Twenty-eight patients (90%) of the patients in the post-implementation cohort acknowledged awareness of the need for additional vaccines, whereas 44 (46%) of patients in the pre-implementation cohort acknowledged awareness ( p = 0.000043).

Conclusion

A post-splenectomy counseling service led to improved rates of patient reported adherence to booster vaccines, as well as increased awareness for need to revaccinate.

Outcomes of limited resection for patients with intraductal papillary mucinous neoplasm of the pancreas: A single-center experience

BACKGROUND

/ObjectivesThe aim of this study was to clarify the oncological outcomes of patients with intraductal papillary mucinous neoplasm (IPMN) who underwent limited resection (LR).

METHODS

This retrospective study analyzed the data of 110 patients with IPMN. Patients with IPMN without a history of pancreatitis who had neither tumor infiltration nor regional lymph node swelling on imaging findings underwent LR. We assessed the oncological outcomes of LR for patients with IPMN by comparing the surgical outcomes of LR and standard resection.

RESULTS

LR was performed in 50 patients (45.5%), including duodenum-preserving pancreatic head resection (n = 31), middle-pancreatectomy (n = 12), spleen-preserving distal pancreatectomy (n = 3), total parenchymal pancreatectomy (n = 3), and partial resection (n = 1). In the LR group, 18 patients had postoperative complications of Clavien-Dindo classification ≥ IIIa. After histopathological examination, the presence of high-grade dysplasia (HGD) and invasive carcinoma (IC) were observed in nine and three patients, respectively, in the LR group, and eight and 22 patients, respectively, in the standard resection group. There was a significant difference in the histopathological diagnosis of IC between the two groups (p < 0.001). Finally, in the LR group, postoperative recurrences occurred in three patients, and the 5-, 10-, and 15-year disease-specific survival rates were all 97.0%.

CONCLUSIONS

For patients with IPMN judged to have no infiltrating lesions based on the detailed imaging examination, LR is acceptable and may be considered as an alternative to standard resection.

Outcome of autoimmune cytopenia after hematopoietic cell transplantation in primary immunodeficiency

BACKGROUND

Post hematopoietic cell transplantation (HCT) autoimmune cytopenia (AIC) is a potentially life-threatening complication, but studies focusing on large cohorts of patients transplanted for primary immunodeficiency are lacking.

OBJECTIVES

This study sought to determine the incidence, risk factors, and outcomes of post-HCT AIC and B-lymphocyte function following rituximab.

METHODS

We retrospectively studied 502 children with primary immunodeficiency who were transplanted at our center between 1987 and 2018.

RESULTS

Thirty-six patients (9%) developed post-HCT AIC, with a median onset of 6.5 months post-HCT. On univariate analysis, pre-HCT AIC, mismatched donor, alemtuzumab, anti-thymocyte antiglobulin, and acute and chronic graft versus host disease were significantly associated with post-HCT AIC. After multivariate analysis, alemtuzumab (subdistribution hazard ratio, 9.0; 95% CI, 1.50-54.0; P = .02) was independently associated with post-HCT AIC. Corticosteroid and high-dose intravenous immunoglobulin achieved remission in 50% (n = 18), additional rituximab led to remission in 25% (n = 9), and the remaining 25% were treated with a combination of various modalities including sirolimus (n = 5), bortezomib (n = 3), mycophenolate mofetil (n = 2), splenectomy (n = 2), and second HCT (n = 3). The mortality of post-HCT AIC reduced from 25% (4 of 16) prior to 2011 to 5% (1 of 20) after 2011. The median follow-up of 5.8 years (range, 0.4 to 29.1 years) showed that 26 of 30 survivors (87%) were in complete remission, and 4 were in remission with ongoing sirolimus and low-dose steroids. Of the 17 who received rituximab, 7 had B-lymphocyte recovery, 5 had persistent low B-lymphocyte count and remained on intravenous immunoglobulin replacement, 2 had second HCT, and 3 died.

CONCLUSIONS

The frequency of post HCT AIC in our cohort was 9%, and the most significant risk factors for its occurrence were the presence of graft versus host disease and the use of alemtuzumab.

Complications in the adult asplenic patient: A review for the emergency clinician

BACKGROUND

The spleen performs several important physiologic functions. However, patients can have functional asplenia or have their spleen removed for a number of reasons, which can put them at risk for several dangerous complications.

OBJECTIVE

This narrative review provides a focused evaluation of adult asplenic patients and complications in the emergency departing setting.

DISCUSSION

The spleen plays integral roles in the immune and reticuloendothelial systems and also modulates the inflammatory and coagulation cascades. Asplenia refers to the anatomic or physiologic loss of splenic function, which may be due to trauma, immunological, hematological, or oncological etiologies. Asplenic patients are at risk for several complications including infection, arterial and venous thrombosis, and pulmonary hypertension. Fever in an asplenic patient and overwhelming post-splenectomy infection (OPSI) are medical emergencies with a high mortality and require rapid evaluation and management with broad-spectrum antibiotics. Asplenic patients are at increased risk of arterial thrombosis, such as coronary artery disease, and venous thrombosis including deep venous thrombosis, pulmonary embolism, and splenic and portal vein thrombosis. Management of venous thrombosis includes anticoagulation. Pulmonary hypertension with associated right ventricular dysfunction may also occur in asplenia. These patients require hemodynamic stabilization with an emphasis on inciting causes and treatment of the pulmonary hypertension.

CONCLUSIONS

The spleen is an integral organ involved in several physiologic functions. Asplenia, or absence of spleen function, is associated with severe complications. Knowledge of these complications can improve the care of these patients.

Update on the "Choosing Wisely" initiative in infectious diseases in Germany

Purpose

The Choosing Wisely^® initiative is an international campaign addressing over- and underuse of diagnostic and therapeutic measures in infectious diseases among others. Since 2016, the German Society for Infectious Diseases (DGI) has constantly designed new items in this regard. Here we report the most recent recommendations.

Methods

The recommendations of the DGI are part of the “Klug entscheiden” initiative of the German Society of Internal Medicine (DGIM). Topics for the new items were suggested by members of the DGI, checked for scientific evidence and consented within the DGI and the DGIM before publication.

Results

The new recommendations are: (1) individuals with immune-suppression, advanced liver cirrhosis or renal insufficiency should receive a dual pneumococcal vaccination. (2) In case of positive blood cultures with Candida spp. thorough diagnostics and treatment should be initiated. (3) In case of suspected meningitis, adult patients should receive dexamethasone and antibiotics immediately after venipuncture for blood cultures and before potential imaging. (4) In case of suspected meningitis a CT scan before lumbar puncture should not be ordered—except for symptoms indicating high CSF pressure or focal brain pathology or in cases of severe immune-suppression. (5) In patients with suspected severe infections, a minimum of two pairs of blood cultures should be drawn using separate venipunctures prior to antibiotic therapy—regardless of body temperature. There is no need of a minimum time interval in between the blood draws.

Conclusion

Applying these new Choosing Wisely^® recommendations will increase patient safety and the value of health care.

Pneumococcal purpura fulminans in asplenic or hyposplenic patients: a French multicenter exposed-unexposed retrospective cohort study

Background

Pneumococcal infections remain the main cause of overwhelming post-splenectomy infections, and purpura fulminans may develop in almost 20% of patients with overwhelming post-splenectomy infection. We aimed at describing the impact of asplenia/hyposplenia on the clinical features and the outcomes of adult patients admitted to the intensive care unit (ICU) for pneumococcal purpura fulminans.

Methods

A 17-year national multicenter retrospective cohort study included adult patients admitted to 55 French ICUs for an infectious purpura fulminans from 2000 to 2016. Patients with pneumococcal purpura fulminans were analyzed according to the absence or presence of asplenia/hyposplenia.

Results

Among the 306 patients admitted to the ICU for purpura fulminans, 67 (22%) had a pneumococcal purpura fulminans, of whom 34 (51%) had asplenia (n = 29/34, 85%) or hyposplenia (n = 5/34, 15%) and 33 (49%) had eusplenia. The prevalence of pneumococcal purpura fulminans was seven times higher in asplenic/hyposplenic patients compared to eusplenic patients with purpura fulminans (n = 34/39, 87% vs. n = 33/267, 12%; p < 0.001). The median time interval between the occurrence of asplenia/hyposplenia and ICU admission was 20 [9–32] years. Pneumococcal vaccine coverage was 35% in asplenic/hyposplenic patients. Purpura was more frequently reported before ICU admission in asplenic/hyposplenic patients (n = 25/34, 73% vs. n = 13/33, 39%; p = 0.01). The rate of bacteremia did not differ between asplenic/hyposplenic and eusplenic patients (n = 31/34, 91% vs n = 27/33, 82%; p = 0.261). SAPS II (60 ± 14 vs. 60 ± 18; p = 0.244) and SOFA (13 [1–5] vs. 14 [1–4, 6]; p = 0.48) scores did not differ between asplenic/hyposplenic and eusplenic patients. There were no significant differences between asplenic/hyposplenic and eusplenic patients regarding the rate of limb amputation (n = 9/34, 26% vs. 15/33, 45%; p = 0.11) and hospital mortality (n = 20/34, 59% vs. n = 15/33, 45%; p = 0.27).

Conclusions

Half of pneumococcal purpura fulminans episodes occurred in asplenic or hyposplenic patients. Pneumococcal vaccine coverage was reported in one third of asplenic/hyposplenic patients. Half of pneumococcal purpura fulminans episodes occurred more than 20 years after splenectomy. Outcomes of pneumococcal purpura fulminans did not show significant differences between patients with or without asplenia or hyposplenia, although the small number of patients included limited our power to detect potential differences between groups.

A Single-Center Prospective Cohort Study on Postsplenectomy Sepsis and its Prevention

Background

This study evaluated the impact of a dedicated outpatient service on vaccination uptake after splenectomy and on the incidence of postsplenectomy sepsis.

Methods

From 2009 to 2016 at the University Hospital Freiburg (Germany), asplenic patients were referred to a dedicated outpatient service, provided with comprehensive preventive care including vaccinations, and enrolled in a prospective cohort study. The impact of the service on vaccination uptake and the occurrence of severe sepsis/septic shock was compared between patients who had splenectomy (or were asplenic) within 3 months of study entry (“early study entry”) and those who had splenectomy (or were asplenic) >3 months before study entry (“delayed study entry”).

Results

A total of 459 asplenic patients were enrolled, and 426 patients were followed prospectively over a median period of 2.9 years. Pneumococcal vaccine uptake within 3 months of splenectomy or first diagnosis of asplenia was 27% vs 71% among delayed study entry and early study entry patients, respectively (P < .001). Forty-four episodes of severe sepsis or septic shock occurred in study patients: 22 after study entry and 22 before study entry. Streptococcus pneumoniae was more frequent among sepsis episodes that occurred before study entry (8/22) than after study entry (1/22 episodes). For episodes occurring after study entry, only a higher Charlson comorbidity index score was significantly associated with severe sepsis/septic shock postsplenectomy.

Conclusions

With dedicated outpatient care, high uptake of pneumococcal vaccination postsplenectomy was achieved. Sepsis episodes were largely of nonpneumococcal etiology in patients who had received dedicated postsplenectomy care.

Prevention of post-splenectomy sepsis in patients with asplenia - a study protocol of a controlled trial

Background

Patients with asplenia have a significantly increased lifelong risk of severe invasive infections, particular post-splenectomy sepsis (PSS). Clear preventive measures have been described in the literature, but previous studies found poor implementation of prevention recommendations. Aim of the study is to improve the adherence to guideline-based preventive measures and thereby reduce the incidence of PSS by a novel telephone-delivered intervention that involves both patients and their physicians.

Methods

A prospective controlled, two-armed historical control group design is used to evaluate the new intervention compared to usual care. The intervention for patients includes both educational aspects and, building on the Health Action Process Approach (HAPA), intervention components that promote motivation and planning of preventive measures. For physicians the intervention is primarily information-based. The primary outcome, the adherence to preventative measures, is indicated by a study-specific ‘Preventing PSS-score’ (PrePSS-score), which is assessed at baseline and at 6-months follow-up. Secondary outcomes include, amongst others, patient self-efficacy and action-planning, asplenia-specific health literacy, general self-management and asplenia-specific self-management. In a process-evaluating part of the study interview-data on patients’ and physicians’ evaluation of the intervention will be gathered.

Discussion

This trial will provide evidence about the effectiveness of the novel prevention intervention for asplenic patients. If demonstrated beneficial, the intervention manual will be made publicly available to enable implementation in practice. The experience gained within this trial may also be valuable for prevention strategies in patients with other diseases.

Trial registration

German Clinical Trials Register (DRKS): DRKS00015238; Trial registration date 07. December 2018.

Romiplostim for the Treatment of Immune Thrombocytopenia: Spotlight on Patient Acceptability and Ease of Use

Immune thrombocytopenia (ITP) is an immune-mediated disorder resulting in platelet destruction and subsequent thrombocytopenia. Bleeding symptoms range from mild cutaneous bleeding to life-threatening hemorrhage. Romiplostim, a peptide-antibody fusion product, is a thrombopoietin receptor agonist (TPO-RA) indicated for use in patients with ITP. Romiplostim is US Food and Drug Administration (FDA) approved in children ≥1 year of age with ITP of >6 months' duration who have had an inadequate response to first-line therapies or splenectomy. FDA approval in adults with chronic ITP was expanded in October 2019 to include adults with newly diagnosed (<3 months' duration) and persistent (3-12 months' duration) ITP who demonstrated an inadequate response to first-line therapies, including corticosteroids and immunoglobulins, or splenectomy. The newly published 2019 American Society of Hematology ITP Guidelines place TPO-RAs, including romiplostim, as second-line therapies in both children and adults. Here, we review the use of romiplostim as second-line therapy with a spotlight on health-related quality of life, ease of use, and patient preference.

Disadvantages of Complete No. 10 Lymph Node Dissection in Gastric Cancer and the Possibility of Spleen-Preserving Dissection: Review

Splenic hilar lymph node dissection has been the standard treatment for advanced proximal gastric cancer. Splenectomy is typically performed as part of this procedure. However, splenectomy has some disadvantages, such as increased risk of postoperative complications, especially pancreatic fistula. Moreover, patients who underwent splenectomy are vulnerable to potentially fatal infection caused by encapsulated bacteria. Furthermore, several studies have shown an association of splenectomy with cancer development and increased risk of thromboembolic events. Therefore, splenectomy should be avoided if it does not confer a distinct oncological advantage. Most studies that compared patients who underwent splenectomy and those who did not failed to demonstrate the efficacy of splenectomy. Based on the results of a randomized controlled trial conducted in Japan, prophylactic dissection with splenectomy is no longer recommended in patients with gastric cancer with no invasion of the greater curvature. However, patients with greater curvature invasion or those with remnant gastric cancer still need to undergo splenectomy to facilitate splenic hilar node dissection. Spleen-preserving splenic hilar node dissection is a new procedure that may help delink splenic hilar node dissection and splenectomy. In this review, we examine the evidence pertaining to the efficacy and disadvantages of splenectomy. We discuss the possibility of spleen-preserving surgery for prophylactic splenic hilar node dissection to overcome the disadvantages of splenectomy.

Pneumococcal infection transmission between family members with congenital asplenia: A case report

BACKGROUND

Asplenia, the lack of a spleen, can be congenital and increases susceptibility to severe infections caused by encapsulated bacteria, such as Streptococcus pneumoniae (S. pneumoniae). We report two cases of severe pneumococcal infection in two asplenic family members living in the same household.

CASE SUMMARY

Patient 1, a 38-year-old man with a history of congenital hepatitis B infection and hypospadias, was brought to our emergency department with complaints of cyanosis, cough, and edema of his limbs. He was clinically diagnosed as hyposplenic with overwhelming pneumococcal sepsis. He was admitted to the intensive care unit and was administered antibiotics and catecholaminergic therapy but died 2 h after admission. Patient 2, a 63-year-old woman with a history of type 2 diabetes, was brought to our emergency department one month after admission of Patient 1. She was diagnosed as asplenic with overwhelming pneumococcal sepsis. History-taking revealed that she was the mother of Patient 1 and the two had lived in the same household. She was admitted to the intensive care unit and was rapidly provided antibiotics and catecholaminergic intervention but died one day after admission.

CONCLUSION

Pneumococcal bacteremia caused by virulent S. pneumoniae may be transmitted within households. All residents of households where individuals with pneumococcal bacteremia are living should be educated about the risk of transmissibility. Family members of patients with congenital asplenia/hyposplenia, all family members should be examined to assess their splenic function.

Vaccination and splenectomy in Olmsted County

OBJECTIVES

To determine the long-term impact of vaccination on any postoperative infection in adults who underwent splenectomy.

METHODS

All adults (≥18 years) who underwent splenectomy from 1965 to 2011 in Olmsted County, MN were identified using the Rochester Epidemiology Project. Descriptive statistics, Kaplan-Meier estimates, and Cox proportional hazard ratios were performed.

RESULTS

There were 724 patients who underwent splenectomy; 47% were female with a median age of 55 (35-69) years. Overall vaccination rate (pneumococcal, H influenza, meningococcal) was 62% (n = 449). There were 268 (36%) patients who developed a post-splenectomy infection; most presented with sepsis 148 (55%). The 3 most common infections included pneumonia (124, 17%), bloodstream (67, 9%), and urinary tract infection (49, 7%). Median time to infection was quicker in non-vaccinated compared with vaccinated patients (1.5 [0.1-4.3] vs 3.3 [1.9-9.8] years, P = .01).

CONCLUSION

In this population-based study, the highest risk of infection after splenectomy was in patients who did not receive complete vaccination. Lack of complete vaccination was associated with a reduced time to infection and increased rates of bloodstream infections at 5 years. Infectious complication risk reduced as vaccination protocols improved for all indications except for malignancy. Adults who underwent a splenectomy should continue to receive booster vaccines.

Spontaneous splenic artery aneurysm rupture in a 38-year old female: a case report

Splenic artery aneurysm (SAA) is a rare and extremely difficult diagnosis. A rare case of a ruptured SAA in a 38-year old female, firstly treated with endovascular embolization and then with splenectomy, is presented. A 38-year old female presented to the emergency department with epigastric pain and fainting episodes. Direct catheter angiography revealed a ruptured SAA and distal, as well as proximal coil embolization was performed. Due to abdominal compartment syndrome the patient underwent open surgery with splenic artery ligation and splenectomy. Postoperative she showed signs of sepsis and was treated with i.v. fluids, steroids, packed red blood cells, platelets, fresh frozen plasma and antimicrobial treatment. Additionally, a multidrug resistant Acinetobacter baumanni was yielded from the urine culture. She had a satisfactory recovery. She is followed up a total of 5 years with no signs of overwhelming post-splenectomy infection syndrome. Direct catheter angiography is a very helpful option in diagnosis, as well as treatment, but a close monitoring after embolization is essential. Furthermore, post-splenectomy sepsis is a severe disease with high mortality rates that requires immediate appropriate treatment.

Outcomes after splenectomy in children: a 48-year population-based study

PURPOSE

In children who have undergone splenectomy, there may be impaired immunologic function and an increased risk of infection. We aimed to define the long-term rate of and risk factors for post-splenectomy infection using a population-based cohort study.

METHODS

All children (< 18 years) who underwent splenectomy from 1966 to 2011 in Olmsted County, MN were identified using the Rochester Epidemiology Project (REP). Descriptive statistics, Kaplan-Meier estimates, and Cox Proportional hazard ratios were performed to evaluate for risk factors associated with developing infection.

RESULTS

Ninety patients underwent splenectomy and 46% were female. Indications included trauma (42%), benign hematologic disease (33%), malignancy (13%), and other (11%). Most were performed open. Vaccination was completed in (72%) for pneumococcal, H. influenza, and meningococcal vectors. Nineteen patients developed infection, and associated factors included non-traumatic, non-malignant disease [HR 4.83 (1.18-19.85)], and performance of multiple surgical procedures [HR 2.80 (1.09-7.21)]. Estimated survival free of infection rates at 15 and 20 years following surgery was both 97%.

CONCLUSIONS

After splenectomy in children, most patients do not develop infection. Nearly three-quarters of patients were vaccinated with the lowest rates in patients that underwent a splenectomy for trauma. In patients who received multiple procedures during a splenectomy, the infection risk was higher.

Origin and differentiation trajectories of fibroblastic reticular cells in the splenic white pulp

The splenic white pulp is underpinned by poorly characterized stromal cells that demarcate distinct immune cell microenvironments. Here we establish fibroblastic reticular cell (FRC)-specific fate-mapping in mice to define their embryonic origin and differentiation trajectories. Our data show that all reticular cell subsets descend from multipotent progenitors emerging at embryonic day 19.5 from periarterial progenitors. Commitment of FRC progenitors is concluded during the first week of postnatal life through occupation of niches along developing central arterioles. Single cell transcriptomic analysis facilitated deconvolution of FRC differentiation trajectories and indicated that perivascular reticular cells function both as adult lymphoid organizer cells and mural cell progenitors. The lymphotoxin-β receptor-independent sustenance of postnatal progenitor stemness unveils that systemic immune surveillance in the splenic white pulp is governed through subset specification of reticular cells from a multipotent periarterial progenitor cell. In sum, the finding that discrete signaling events in perivascular niches determine the differentiation trajectories of reticular cell networks explains the development of distinct microenvironmental niches in secondary and tertiary lymphoid tissues that are crucial for the induction and regulation of innate and adaptive immune processes.

The white pulp of spleen is an important immune structure dynamically modulated during development and immune responses. Here the authors define, using multi-color lineage tracing and single-cell transcriptome analysis, the subset distribution and differentiation trajectory of fibroblastic reticular cells to serve structural insights for splenic white pulps.

Total pancreatectomy for pancreatic malignancy with preservation of the spleen

BACKGROUND

Total pancreatectomy may be necessary to achieve margin-negative resection for pancreatic cancer. However, despite the desirability of saving the spleen, the feasibility, safety, and oncological outcomes of spleen-preserving total pancreatectomy have not been studied in patients with malignancy involving the pancreatic neck or proximal body. The aim of this study was to report the efficacy of spleen-preserving total pancreatectomy using the Warshaw technique for patients with pancreatic malignancies.

METHODS

A retrospective analysis of patients who underwent total pancreatectomy for malignant pancreatic diseases between December 2006 and January 2018 focused on comparing the clinical outcomes between conventional operations with splenectomy and spleen-preserving total pancreatectomy using the Warshaw technique.

RESULTS

Thirty-eight patients among a total of 59 total pancreatectomies had the spleen preservation by the Warshaw operation. In this series, the pancreatic ductal adenocarcinomas resected with the Warshaw technique were of smaller tumor size but had greater rates of vascular invasion, resulting in the more frequent vascular resection. No patients had splenic complications requiring splenectomy, but two patients intended to have the Warshaw operation were converted to splenectomy because of splenic malperfusion. Asymptomatic perigastric varices were noted in 4 patients. Postoperative morbidity and mortality were comparable between the Warshaw and conventional operation groups. Recurrence-free and overall survival was similar in both groups.

CONCLUSION

In patients with pancreatic malignancy, total pancreatectomy with preservation of the spleen using the Warshaw technique achieves outcomes comparable with conventional total pancreatectomy with splenectomy in selected patients.

Assessment of Postvaccine Immunity against Streptococcus pneumoniae in Patients with Asplenia, including an Analysis of Its Impact on Bacterial Flora of the Upper Respiratory Tract and Incidence of Infections

S. pneumoniae is a microorganism that may cause a serious threat in postsplenectomy patients due to a potentially invasive course of infection. In order to assess a protective activity after vaccination with the 23-valent vaccine, we made an analysis of the level of antibodies in patients with asplenia compared to a control group of healthy donors. Additionally, colonization by potentially pathogenic microorganisms of the upper respiratory tract was analyzed to determine the carrier state by strains with vaccine serotype. No such strains were found in the research, yet three non-vaccine-serotype strains were found. Colonization of the upper respiratory tract by potentially pathogenic microorganisms may be connected with increased susceptibility observed and incidence of infections in patients with asplenia. However, colonization by S. pneumoniae may not have an effect on the level of specific antibodies with the 23-valent vaccine against S. pneumoniae (PPV23) in postsplenectomy patients and healthy people. The response to vaccination against S. pneumoniae showed a lower level of specific antibodies in patients with splenectomy performed more than 2 years before the test than in patients with a recently removed spleen, i.e., from 1 month to 2 years before the test. Vaccination against pneumococci also has positive effects on incidence of other etiology infections, which is of high significance in the prophylaxis of infectious diseases in this group of patients.

Clinical spectrum and short-term outcome of adult patients with purpura fulminans: a French multicenter retrospective cohort study

PURPOSE

Data on purpura fulminans (PF) in adult patients are scarce and mainly limited to meningococcal infections. Our aim has been to report the clinical features and outcomes of adult patients admitted in the intensive care unit (ICU) for an infectious PF, as well as the predictive factors for limb amputation and mortality.

METHODS

A 17-year national multicenter retrospective cohort study in 55 ICUs in France from 2000 to 2016, including adult patients admitted for an infectious PF defined by a sudden and extensive purpura, together with the need for vasopressor support. Primary outcome variables included hospital mortality and amputation during the follow-up period (time between ICU admission and amputation, death or end of follow-up).

RESULTS

Among the 306 included patients, 126 (41.2%; 95% CI 35.6-46.9) died and 180 (58.8%; 95% CI 53.3-64.3) survived during the follow-up period [13 (3-24) days], including 51/180 patients (28.3%, 95% CI 21.9-35.5) who eventually required limb amputations, with a median number of 3 (1-4) limbs amputated. The two predominantly identified microorganisms were Neisseria meningitidis (63.7%) and Streptococcus pneumoniae (21.9%). By multivariable Cox model, SAPS II [hazard-ratio (HR) = 1.03 (1.02-1.04); p < 0.001], lower leucocytes [HR 0.83 (0.69-0.99); p = 0.034] and platelet counts [HR 0.77 (0.60-0.91); p = 0.007], and arterial blood lactate levels [HR 2.71 (1.68-4.38); p < 0.001] were independently associated with hospital death, while a neck stiffness [HR 0.51 (0.28-0.92); p = 0.026] was a protective factor. Infection with Streptococcus pneumoniae [sub-hazard ratio 1.89 (1.06-3.38); p = 0.032], together with arterial lactate levels and ICU admission temperature, was independently associated with amputation by a competing risks analysis.

CONCLUSION

Purpura fulminans carries a high mortality and morbidity. Pneumococcal PF leads to a higher risk of amputation.

TRIALS REGISTRATION

NCT03216577.